Wound Management Flashcards
What is a pressure ulcer?
A pressure ulcer is localised injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear.
What is stage 1 of pressure ulcer called?
Persistent redness.
What is stage 2 of pressure ulcer called?
Partial thickness skin loss.
What is stage 3 of pressure ulcer called?
Full thickness skin loss.
What is stage 4 of pressure ulcer called?
Full thickness tissue loss.
Describe stage 1 of PU.
- Redness of intact skin.
- Discolouration of the skin, warmth, oedema or hardness.
Describe stage 2 of PU.
-Partial thickness of skin loss involving epidermis & dermis.
Describe stage 3 of PU.
-Full thickness skin loss involving damage to subcutaneous tissue.
Describe stage 4 of PU.
-Extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures.
What does S.S.K.I.N stand for?
- Surface: patients have the right support.
- Skin inspection: show patients and carers what to look for.
- Keep your patients moving.
- Nutrition/Hydration: right diet and plenty of fluids.
Define wound.
A breech in the epidermis or dermis that initiates a process of repair, which can be related to trauma or pathological changes.
Define acute wounds.
A wound that heal in an expected time frame without delay. (trauma)
Define chronic wounds.
Wounds that have delayed healing. (pathological changes)
Why does chronic wounds have delayed healing?
Usually because patients have venous disease. Venous blood cannot easily return up the leg due to damage to veins. This causes skin changes which may result in ulceration.
What are the four phases of healing?
- Haemostasis: minimising blood loss (blood clots).
- Inflammation: ‘clean up’ in skin tissues by mobilising host defences.
- Proliferation: repair any defects or formation of scar tissue (epithelialisation)
- Maturation: gradual increase in skin strength.
